NSE 103 - Intro to Health. Assessment
(Vital sign testing)
what is subjective data? - Answer data the patient tells you
what are symptoms? - Answer something the client feels
what are signs? - Answer observable findings
what is objective data - Answer what you observe and can measure
what is clinical judgement? - Answer determination about a client's health status
deciding their capacity to engage in care and whether action should be taken or not
what is clinical reasoning? - Answer the thinking process by which a nurse reaches a clinical
judgement
what is clinical deterioration? - Answer a worsening clinical state related to physiological
decompensation
what are priorities of care? - Answer what actions are most important to take first, and which
can follow
what are the levels of Maslow’s hierarchy of needs from top to bottom - Answer self-
actualization
esteem
social
security
physiological
what are the levels of priority of care? - Answer first, second, third
, what is first level priority of care? - Answer problems that reflect critical findings & require
urgent action
what is second level priority of care? - Answer problems that may lead to clinical
deterioration / may become life threatening
requires prompt action
what is third level priority of care? - Answer problems that are not acute in nature
not urgent & can wait until the client is stable
what are the four types of interventions? - Answer effective
ineffective
unrelated
contraindicated
what are the types of health assessments? - Answer primary survey
focussed assessment
head to toe assessment
complete health assessment
what are the components of a primary survey? - Answer ABCDE (Airway, breathing,
circulation, disability and exposure)
what does D stand for in ABCDE (primary survey)? what does it mean? - Answer disability -
level of consciousness, speech, pain
(Vital sign testing)
what is subjective data? - Answer data the patient tells you
what are symptoms? - Answer something the client feels
what are signs? - Answer observable findings
what is objective data - Answer what you observe and can measure
what is clinical judgement? - Answer determination about a client's health status
deciding their capacity to engage in care and whether action should be taken or not
what is clinical reasoning? - Answer the thinking process by which a nurse reaches a clinical
judgement
what is clinical deterioration? - Answer a worsening clinical state related to physiological
decompensation
what are priorities of care? - Answer what actions are most important to take first, and which
can follow
what are the levels of Maslow’s hierarchy of needs from top to bottom - Answer self-
actualization
esteem
social
security
physiological
what are the levels of priority of care? - Answer first, second, third
, what is first level priority of care? - Answer problems that reflect critical findings & require
urgent action
what is second level priority of care? - Answer problems that may lead to clinical
deterioration / may become life threatening
requires prompt action
what is third level priority of care? - Answer problems that are not acute in nature
not urgent & can wait until the client is stable
what are the four types of interventions? - Answer effective
ineffective
unrelated
contraindicated
what are the types of health assessments? - Answer primary survey
focussed assessment
head to toe assessment
complete health assessment
what are the components of a primary survey? - Answer ABCDE (Airway, breathing,
circulation, disability and exposure)
what does D stand for in ABCDE (primary survey)? what does it mean? - Answer disability -
level of consciousness, speech, pain
